Beauty Knows No Pain

“Are you here for the convention?” The inquiring woman behind the registration table at the San Francisco Marriott seems not to notice that the video monitor beside her is oozing gore. On the monitor, an anesthetized patient's face is being sliced open like a mango, exposing a rubbery layer of underlying muscle along the chin line. The camera gamely zooms in for a close-up, and for several moments, the monitor is completely filled by what looks like red throbbing gristle.

“Sir?” the woman asks again. “Are you here for the convention?” “Uh — oh, sorry, yeah,” I reply. “I was just watching –“ “Here,” the woman says. “Have a program.”

Thanks. I had the feeling this convention — the 28th annual meeting of the American Society for Aesthetic Plastic Surgery — would be the sort of gathering where you wouldn't be able to identify the blood-splattered internal organ without a program.

The Marriott's Golden Gate Ballroom has the expectant buzz of a concert hall just before a big show. Which is only appropriate, since plastic surgeons are in many ways the rock stars of the medical profession. They live the good life, play the lead role in pulsating videos that are often difficult to watch and make their living by deliberately breaking the rules. In the plastic surgeons' case, the rule they regularly break is the central tenet of the Hippocratic Oath: First, do no harm. Cosmetic surgeons make their nut by taking perfectly healthy people, and first, doing them harm. They are men of science (and they usually are men) who have elevated the dissembly and reassembly of human beings into an art form. Their income ranks among the highest of any medical specialist, averaging $180,000 per year net, with the top practitioners often making in excess of $1 million. And like rock stars, plastic surgeons have an increasingly difficult time separating their “art” from commercial pressures. They don't like to think of themselves as being motivated by money, and they will go to great lengths to mask that reality not only from the public, but from themselves. Yet at a convention, surrounded by their own, plastic surgeons begin to let what's left of their hair down. An early sweep of the convention hall reveals a crazy quilt of shop talk.

“You look like you got a tan,” says one surgeon. “Oh yeah,” replies his younger colleague. “We were skiing in Jackson Hole for five days.”

“Was it cold?” “No, it was almost too hot …” “… You know what I mean — they have throat cancer and they just have that look,” says another doctor, continuing a second conversation.

“… No, no, you separate it entirely from the gland,” says a surgeon in a third discussion.

“Entirely?” asks his colleague. “Completely,” the surgeon replies, with a note of finality. “Then you fold the breast over.” The surgeon makes a motion with his hands as though he were flipping an omelet.

Dozens of “before” and “after” photos of plastic surgery patients line the walls of the exhibition booths like mug shots at a post office. The surgeons ignore the photographs, probably because they've seen them all before. And after. The droopy, world-weary faces of the “before” shots, taken from unflattering nose-hair angles with the camera flash set to “stun.” The finely sculpted, doll-like faces of the “after” photos, the lighting softly caressing the raised cheekbones, the skin lovingly airbrushed to remove whatever blemish the scalpel couldn't excise. For some subjects, this was not their first time under the cosmetic knife. As such, their before shots were actually after shots from previous surgeries, forming a continuous Msbius strip of before and after, after and before.

The American Society for Aesthetic Plastic Surgery (ASAPS) represents about 1,100 plastic surgeons nationwide, and most of them seem to have made it to the Marriott convention. Every year, the group meets at an appropriately serious venue (next year's meeting is already scheduled for Walt Disney World) to view new surgical equipment, attend scientific presentations and, most of all, rub padded wool-blend shoulders with their distinguished colleagues. Many of the older surgeons look like Germany's Chancellor Helmut Kohl — slightly paunchy in a prosperous Bavarian way, with swept-back silver hair, a ruddy face and an aura of authority that hangs over them like expensive cologne.

The younger surgeons in their late thirties and early forties look tanned and dashing, as though they had recently returned from Club Med vacations on their own private planes. In a way, it's not surprising that certain physical features predominate among plastic surgeons — the profession is an exclusive members-only gene pool. At this convention, affirmative action is just another Sunday-morning talk show topic. Among nearly 1,000 attendees, I count fewer than a dozen female surgeons and even fewer African Americans. You'd be hard pressed to find this many white males in one room anywhere, unless you dropped in on the U.S. Senate in session.Many of the wives and girlfriends accompanying the conventioneers display the taut, vaguely Cubist features that are the hallmark of repeated plastic surgery. One woman in particular — a striking blonde in her late twenties — causes quite a stir. She sports iridescent skin pulled so tightly over her cheekbones it looks like Saran Wrap, and a pair of gravity-defying breasts that jut straight out of her chest, like Amazon breastplates. Picture Total Hair Barbie with implants.

“Did you see her?” one of the female exhibitors asks incredulously. “She must have gotten them done recently because they haven't — fallen.” Then, as the breast woman's husband passes — a plastic surgeon in his late forties — the exhibitor's eyes narrow and she adds, “The person I feel sorry for is his first wife.”

Now, now — no need to be catty. There could be a perfectly innocent explanation as to why many of the plastic surgeons' companions look about 20 years younger than the docs. Maybe the surgeons were so dedicated to learning their craft and poring over complex technical journals that they all got married later in life — to very young women with boob jobs. Then again, if many of the surgeons did trade in their first wives as soon as they hit middle age, they would merely be reflecting the cultural attitudes that have made cosmetic surgery such a lucrative business — a shallow preoccupation with the beauty of youth coupled with a pathological horror of aging. [page]

Of course, not all plastic surgery is performed in the service of vanity. Some plastic surgeons are nothing less than miracle workers, and if you are a plastic surgeon reading this, rest assured — we are talking about you. Breakthrough reconstructive procedures have been developed for patients who have lost breasts to cancer, allowing the women to feel whole again. Developments in new laser and radiosurgery equipment have enabled doctors to correct cleft lips, cleft palates, scars from burns and deformed noses that were inoperable a few years ago. Interplast, a nonprofit organization founded 25 years ago by Stanford University physician Donald Laub, even performs free reconstructive surgery in developing countries, while helping train local medical personnel. Last December, an Interplast team completed its third trip to Vietnam, treating war victims and the congenitally impaired.

But don't confuse these altruistic apostles of reconstructive surgery with the cosmetic surgeons who have descended on the Marriott. Cosmetic surgeons don't tour the globe performing pro bono butt lifts, although the world might be a happier place if they did. The world still awaits the formation of Interbutt, the nonprofit organization dedicated to easing the load of big-butted people and the people who love them.

The best way to distinguish reconstructive surgery from cosmetic surgery is to determine who paid for it — insurance companies don't reimburse for elective procedures. Every facelift, tummy tuck, breast enlargement, rhinoplasty and pectoral implantation ordered for aesthetic reasons must be paid for directly by the patient.

Once a small and somewhat shadowy subset of plastic surgery, cosmetic surgery now dwarfs its more socially responsible reconstructive parent, accounting for 80 percent of all the money currently spent on all plastic surgery. The cosmetic surgery industry in the U.S. currently grosses (an appropriate word, as we'll see) $300 million a year, and is growing at a 10 percent annual rate. About 85 percent of all cosmetic procedures are performed on women, although the growing popularity of pectoral implants and penile surgeries is likely to close and suture the gender gap.

At one of the convention booths, a surgeon and a salesman are bent over the new Surgitron from Ellman International, a handheld radiosurgical “scalpel” that makes incisions using high-frequency radio pulses. According to the company's glossy brochure addressed to plastic surgeons, the Surgitron will “increase your revenue” and “increase your range of procedures” while serving to “eliminate unfavorable postoperative conditions such as trauma, pain, swelling and infection.” It was a timely reminder that one person's living nightmare is another person's unfavorable postoperative condition.

“Here, let me show you,” the Ellman rep says, grabbing the device. Pulling out a piece of uncooked meat — a small club steak — the salesman proceeds to perform “surgery” on it. He waves the device over the meat with one hand while cranking up a dial on a blue control box with the other. A 4 million cycles-per-second electric pulse leaps from the scalpel's microsharp tungsten alloy tip. Within seconds, the meat smolders and emits an acrid “electric” smell, like the odor a hair dryer gives off after being run too long. The surface of the slab of meat opens and reveals a fleshy pink interior with crisscrossed veins.

“Hmmm,” the surgeon says, slipping on his glasses to peer at the “after” results.

The patient registers no complaint.

The exhibition hall is laid out like a giant supermarket of plastic surgery, with food items sitting in for patients. Over at booth 58, a knot of surgeons watch the demonstration of a laser burning tiny black holes in a large, ripe tomato.

“You can see I'm barely breaking the surface of the skin,” says Sidneye Azar, a representative for Sharplan Lasers Inc., as he zaps the tomato with a Silktouch surgical laser. “You can set the controls to any thickness — whoops — I broke the surface a little there. I'm still learning this. But you get the idea.”

Tiny wisps of smoke curl up from where the laser made contact, and the area where Azar accidentally broke the surface of the tomato dribbles red jelly. Several surgeons walk off to another booth, the word “mal-practice” echoing mightily in their heads.

If demonstrations such as this make plastic surgery seem primitive, it's because in many ways it still is. But don't expect the Muzak in the doctor's waiting room to be replaced by tribal drumming anytime soon.

One of the first recorded accounts of the type of surgery that would later become known as “plastic” (the word is derived from the Greek word plastikos, meaning to mold or give form) is documented in the Sushruta Samhita, a three-volume encyclopedia of medicine written in India more than 2,000 years ago. One passage describes “the affixing of an artificial nose,” an only somewhat cruder form of what's now known as a rhinoplasty: “First the leaf of a creeper, long and broad enough to fully cover the whole of the severed or clipped off part should be gathered, and a patch of living flesh, equal in dimension to the preceding leaf should be sliced off (from down upward) from the region of the cheek, and after scarifying it with a knife, swiftly adhered to the severed nose.” Following the procedure, the patient was anointed with oils, given clarified butter and treated with purgatives — not terribly different than the alcohol rubdown, two Tylenols and enema given to many patients today. [page]

In modern terms, this rudimentary slicing and dicing amounted to reconstructive, rather than elective, surgery. The roots of modern elective surgery performed for aesthetic purposes can be traced to ancient practices of ritual scarification. In scarification, the skin is gashed with a knife and salt is rubbed into the wounds so that raised welts are formed. Among the Yoruba in Africa, scarification was performed to indicate lineage, while Sudanese women etched scars in their skin to mark significant milestones in their lives, such as the onset of menstruation or the birth of a child. In Japan, women wore facial tattoos that denoted their domestic status, and at significant periods in their life, they had their cheeks and eyebrows slashed with obsidian and flint.

Today, the native tribes of Palm Springs, Beverly Hills and the Upper East Side ritualistically mark the onset of middle age by having sacks of saline inserted under the muscle of their breasts or having the skin in their face and neck pulled back and tightened. Among the males of the tribe, the common belief that genital size is directly linked to one's performance as tribal leader results in the practice of having fat injected into the shaft of the penis to enlarge its circumference. While most civilized clan members today reject ancient forms of tattooing as a descent into primitivism, modern micropigmentation is very popular, which surgically applies pigment under the eye as permanent makeup. We've come a long way, baby!

At booth 79, a surgically enhanced registered nurse named Paula Lochmandy is hawking her book, Beauty Knows No Pain: The Anatomy of a Successful Facelift. The book combines navel gazing and jowl raising, alternately describing how Lochmandy came to terms with her Inner Child while at the same time dispatching an ace plastic surgeon to help her reclaim her lost youth. “Putting the aging process on hold may not be for everyone,” intones an overcautious cover blurb, “but now an informed decision can be made without boring textbooks or sensational talk-show hype.”

Lochmandy looks a bit tightly wound standing behind a pile of her unsold books, although that just could be the result of her facelift. What makes for a “successful” facelift, anyway? Is it when the number of people who say you look “fabulous” is greater than the number of people who whisper and point at you from across the room? Is it when you look only a little like someone who just emerged from a wind tunnel? Is it when the face staring back at you in the mirror is unrecognizable as your own? Lochmandy credits her operation with nothing less than “reclaiming my femininity,” which calls into question what her version of femininity was in the first place.

Writers such as Naomi Wolf and Susan Faludi argue that the plastic surgery stampede is caused by societal pressures that command women to stay forever young. In The Beauty Myth, Wolf calls plastic surgery “a political weapon” wielded against women and says the notion that women freely choose to have plastic surgery is an illusion. “Women's choice in the Age of Surgery is not free,” Wolf writes.

“That's a load of crap,” counters USA Today fashion writer Elizabeth Snead, who says she's “very happy” with her surgically enhanced breasts, nose and lips. “Yeah, it's wrong if you're having plastic surgery because you think men are going to drop at your feet. But if you honestly think it's going to make you feel better about yourself, I think you should do it. Most people who have had cosmetic surgery don't talk about it, but I think more of them should.”

But Snead concedes that the field of plastic surgery is “incredibly sexist,” consisting of invasive procedures performed primarily on women by men. The American Society of Plastic and Reconstructive Surgeons (ASPRS) once argued before the FDA that small breasts were a treatable disease called “micromastia,” a disfiguring malady reparable by — what else — plastic surgery.

At the same time, a parallel condition in men, termed “micropenis,” hasn't received nearly as much tender loving care from the medical establishment. There are two penis-enlargement techniques currently being performed on a limited basis. Surgeons treat the impoverished pecker by injecting fat under the shaft of the penis — sort of liposuction in reverse — and/or partially detaching the ligaments connecting the penis to the pubic bone. Several thousand of these procedures are performed annually, and advertisements for the operation regularly appear in the sports sections of the Chronicle and Examiner. (Physician, heal thyself.)

But in a strongly worded position paper read at the convention, the ASAPS opposed cosmetic penile surgery, calling the fat-injection technique “experimental” and maintaining that the detached ligament procedure “has not been shown to be safe or efficacious.” For plastic surgeons, it showed an uncharacteristic lack of adventure.

“That's because the penis is a real sex organ,” laughs Jane Sprague Zones, chair of the National Women's Health Network.

Despite the space-age polymers and electric knives in his arsenal, the work of a modern plastic surgeon (like that of his primitive predecessors) is still largely bone-crunching and flesh-tearing. Abdominal lipectomy — cutely known as a “tummy tuck” — makes the surgery of the Dark Ages seem downright enlightened by comparison. The tummy tuck starts with the surgeon making an incision around the navel and suctioning off abdominal fat, which requires that a two-foot-long hollow metal tube be shoved under the skin into the underlying fatty layer. The tube is swept back and forth like a fat-sucking Dust Buster and the navel is then cut completely free as the skin and deep fat is separated from the muscle all the way to the ribs.

By this point, the patient resembles one of those clear transparencies in the middle of an anatomy textbook. The abdominal muscles are tightened, the skin is pulled taut, and more fat is suctioned from the sides of the abdomen to even everything out. A new hole is cut in the middle of the abdomen for the repositioned navel — are we having fun yet? — and the incisions are closed with stitches. Patients are fed intravenously for 18 to 48 hours after surgery because the act of vomiting solid food could rip loose internal stitches. Provided there are no serious complications, the tummy-tucked patient leaves the hospital several days later with a repositioned navel, several long, permanent scars — and a temporarily flatter and tighter abdomen. And to think that some people waste their time doing situps. [page]

The most invasive surgical procedures, like tummy tucks, are not much different than they were 30 years ago. But in those three decades the number of plastic surgeries has quintupled, with an estimated 1.5 million people taking the cosmetic cut. California, the nation's restless dream factory, accounts for almost 20 percent of all aesthetic procedures. Florida, New York and Texas follow well behind, while stoic New England is in last place, with the region's six states combining for just 3.1 percent of all cosmetic procedures. The 5,000 members of the ASPRS performed 394,911 aesthetic procedures in 1992, the last year for which complete figures are available. Many other cosmetic procedures by non-ASPRS members go undocumented. An estimated 2 million women — 1 in 60 — have had breast implants.

Breast augmentation typically costs $3,000 to $4,000. A full facelift will set you back $4,500 to $8,500 depending on where you have it done (cities are more expensive) and whether you have general anesthesia and stay in the hospital overnight. Facelifts “last” five to 10 years, although your actual mileage may vary. Liposuction ranges from about $500 for a quick chin-suck to $8,000 for an extensive full-body Hoovering requiring hospitalization. Those delightful tummy tucks can cost in excess of $10,000. Penile enlargement surgery costs up to $6,000, although its boosters insist this is an operation that pays for itself.

A small portion of that plastic surgery gold mine ended up at the condominium-size exhibition booth staffed by the McGhan Medical Corporation, a large manufacturer of breast implants. Until 1992, breast augmentation was the most reliable moneymaker for plastic surgeons — but then the FDA limited the use of silicone implants, following complaints from women ranging from capsular contracture (shrinking of scar tissue around the implant that can cause hardening of the breasts) to concerns that the implants could interfere with mammograms or that leaking silicone gel could damage the immune system. Silicone implants are still approved for breast reconstruction after breast cancer surgery and for certain other medical conditions, but most women currently opt for saline implants, which are available without restriction. (Of the women who receive breast implants, about 80 percent have them for augmentation rather than reconstruction.)

Not surprisingly, the McGhan booth downplays silicone implants, turning the spotlight — literally — on saline. The booth's glass display case features brilliantly spotlighted saline implants, from the modest 195cc model to the Carol Dodaesque 650cc implant. It's the kind of display case you see at head shops, except there's no sign that reads “Please Don't Lean on the Glass” and no one is pressing his nose to the glass and steaming it up. On top of the display case sits, somewhat incongruously, a dish of complimentary Ghirardelli chocolates.

As the silicone breast controversy demonstrates, the growing popularity of plastic surgery hasn't necessarily made it safer. A medical newsletter available at the convention tells of overzealous facial liposuctions that have resulted in a jut-jawed condition known as “the Dick Tracy effect.” Another saga in the newsletter describes an improperly liposuctioned woman “who said that she could reach down to her mid-thigh, grab a handful of skin and pull it up to her groin … these people simply plop like an old pair of golfer's pants.” Plastic surgery's acceptance has been fueled more by social dynamics than scientific advances.

Perhaps as a peace offering, the McGhan booth distributes the best freebie of the convention — a canary-yellow tote bag emblazoned with the company name. By convention's end, practically every surgeon is carrying a McGhan tote, a weird sight for a group of professionals who earn in the six figures. But as KQED discovered decades ago, few people can resist the lure of a free tote bag.

Media images of beauty have been an indispensable catalyst in the plastic surgery explosion. In Hollywood, plastic surgery is considered to be a rudimentary precondition of employment, like taking the gum out of your mouth before a job interview. Meanwhile, television mindlessly supports cosmetic surgery as a transformative experience. Before and after shots are a regular staple of afternoon talk shows, and only occasionally are risks explored or even mentioned. Celebrity books regularly exalt the regenerative powers of plastic surgery. Dolly Parton's recent autobiography even thanks her many plastic surgeons by name and supplies an 800 number for plastic surgery referral. Barbara Walters' TV specials serve as soft-sell infomercials for plastic surgery, with the tastefully nipped-and-tucked interviewer regularly sitting down to chat with surgically altered stars. Many women's magazines are shameless boosters of cosmetic surgery, with breathless accounts of new “breakthrough” procedures surrounded by — surprise! — advertisements for plastic surgeons. Even Cosmopolitan, which occasionally reports on the risks of plastic surgery, features a cover model every month whose Himalayan cleavage sends a very different message.

The American media images of beauty are so Western that some ethnic clients have turned to the knife in a sad attempt to assimilate. There are eye operations for Asians that make the eyes look rounder and procedures for Latinos and African Americans to narrow their noses, making them appear more Caucasian. The illogical extreme of this surgical ethnic cleansing is represented by Michael Jackson, who has managed to obliterate his race and now appears to be working on becoming a different species.

The surgically enhanced body is such a common media presence that it's become the standard for comparison. It's little wonder why so many people are dissatisfied with their God-given bodies when Science promises to do God one better. [page]

Back at the Marriott, the convention is in full swing. Scientific lectures and papers are being presented in the Buena Vista Ballroom, raising topics ranging from “Facelifts — Are We Going in the Right Direction?” and “Aesthetic Lip Augmentation — An Art Form in Progress” to “Blepharoplasty Update — The Good, the Bad and the Ugly.” One scientific presentation, “Surgical Management of the Cocaine Nose,” presents what must be a dream assignment for a plastic surgeon — a patient wealthy enough to blow a hole in his septum through repeated cocaine use and still have enough money left over to afford plastic surgery. The Partnership for a Drug Free America should dump that advertisement of the fried egg sizzling in the pan and instead show a cocaine-ravaged nose being peeled open with surgical retractors. This is your nose during rhinoplasty — any questions?

In the exhibition hall, much of the talk centers around what the medical profession euphemistically terms “building the practice” — what most people on the other end of the stethoscope would call “drumming up new business.” With elective surgery, there's a fine line between serving a need and creating needs, a line many plastic surgeons have long since crossed.

“The plastic surgery pie is being sliced in so many more pieces,” one surgeon complains to his colleague during a coffee break, using an appropriately invasive metaphor. “There are so many other doctors getting into it that it's gotten much harder to build a practice.”

He's right: Any licensed physician can legally call himself a cosmetic plastic surgeon and needn't have ever performed — or even watched — a single cosmetic operation before picking up a scalpel. Attempts to restrict entry into the field have been rebuffed by the medical lobby, so today eye surgeons do brow lifts. Ear, nose and throat surgeons perform facelifts and rhinoplasties. Dermatologists perform derm-abrasions.

Turf wars have erupted between the rival camps. Plastic surgeons who have been “board certified” by the American Board of Plastic Surgery (ABPS) usually insist that they are the most qualified to perform cosmetic surgery. To be certified by the ABPS, doctors must have completed three years of surgical training, two to three years residency in plastic surgery, at least two years of plastic surgery practice, and a written and oral examination in the field.

“I think board certification is extremely important,” says Dr. Brunno Ristow, an ABPS-certified San Francisco plastic surgeon, who says his patients range from socialites to “a woman who sells hot dogs at Candlestick.” “Board certification shows that a surgeon is proficient in several areas. But simply being board certified doesn't mean you're brilliant. And not being board certified doesn't mean you're a crook.”

Not surprisingly, doctors who haven't been certified by the American Board of Plastic Surgery don't think board certification — at least by the ABPS — is such a big deal. There are dozens of self-designated boards that are not officially approved by the AMA's American Board of Medical Specialties. For example, one San Francisco plastic surgeon, while not certified by the American Board of Plastic Surgery, calls himself a “Board Certified Surgeon” in his half-page ad in the Yellow Pages by virtue of his affiliation with the American Academy of Cosmetic Surgery, the American Academy of Facial Plastic and Reconstructive Surgery (which is different than the American Society of Facial Plastic and Reconstructive Surgery), the American College of Surgeons and the Liposuction Society. The doctor in question wouldn't come to the phone to discuss his credentials, but when his receptionist was asked specifically about the American Board of Plastic Surgery certification, she conceded that “he doesn't have that piece of paper.” She did, however, assert that the doctor is “board certified in everything from the neck up” — presumably the patient's neck.

With so many scalpels entering the plastic surgery pie, it's hard for today's plastic surgeons to extract the sort of income to which they're accustomed. In The Complete Book of Plastic Surgery, plastic surgeon Dr. Elizabeth Morgan slams her colleagues with the estimate that as many as 20 percent of board-certified surgeons, and “well above 25 percent” of nonboard-certified surgeons “put commercial goals ahead of their patient's interests.” Even the name of the group meeting at the Marriott tacitly promotes surgical procedures — it's not the American Society of Aesthetic Plastic Surgeons but rather, the American Society for Aesthetic Plastic Surgery.

“Are you maximizing your practice-building opportunities?” asks a pamphlet being distributed by Collagen Biomedical at booth 15. Collagen treatment — a nonsurgical procedure in which bovine protein (read: cow hide) is injected just below the skin's surface to smooth lines and wrinkles — is one of the hot new “practice builders” for plastic surgeons.

Since collagen treatment was introduced in 1981, nearly 1 million people in 28 countries have used the procedure, a figure that will climb if the product's manufacturers have any say in the matter. The pamphlet assures doctors: “Collagen Biomedical is continuing to aggressively target the aging population, positioning Collagen Replacement Therapy as a safe, effective treatment for lines and wrinkles.” You certainly can't go wrong with targeting the “aging population,” since it includes all current members of the human race.

The risks of collagen treatment include allergic reaction, infection and, in some cases, permanent skin discoloration. Collagen could accidentally be injected into a blood vessel and block blood flow, although the manufacturer reassures that this foul-up is rare: “Blood-flow blockage resulting in permanent loss of vision in one eye has been reported once since product introduction in 1981.”

Partial blindness seems a stiff price to pay for a more youthful complexion, but then, beauty knows no pain.

The more common disappointment with collagen treatment is that its benefits are short-lived, usually lasting one to two years or less. The body gradually absorbs the injected collagen, and patients wanting wrinkles smoothed over will need re-treatment. Little wonder that collagen treatment is a great “practice builder”: The procedure is fast, easy and decidedly temporary. [page]

Not far from the collagen display, a color monitor blinks a succession of before and after electronic images. Computer imaging systems allow plastic surgeons to build the practice by showing after pictures to prospective patients before they've had surgery. Mirror Image Technology's Mirror II Aesthetic Imaging System features an Intel 80486-50 computer loaded with 16 megs of RAM and a 540 meg hard drive, which morphs the before into the after. With just a few clicks of the mouse, a digital photo of the patient is seamlessly transformed: jowls tighten, chin lines sharpen, wrinkles vanish and breasts magically inflate.

“You'll get some patients who come in and want to look like Claudia Schiffer,” says Austin Linford, a sales rep demonstrating the Mirror II. “A system like this helps weed out the crazies. And it pays for itself in a month.”

Since the system costs around $30,000, that's not a shabby return on investment. One Dallas plastic surgery practice that used Mirror II found that “the conversion rate of consultation to surgery” surged 53 percent and revenue increased $205,000 in the first five months, according to the company. Of course, the after images shown on the computer before surgery might be quite different from the actual results. For this reason, prospective patients aren't given a print-out of their digitally altered photo, just in case the results fall well short of the promise.Over at booth 51, a company called Tel-a-Patient has devised a way to build the practice before the surgeon even talks to the patient. The firm's digital message-on-hold system “turns telephone 'hold time' into a powerful practice builder,” according to a sales brochure, by bombarding prospective clients with descriptions of available procedures and other “wellness” marketing messages.

Other exhibitors aren't so discreet. Sharplan, a company that manufactures lasers and other surgical equipment, distributes a glossy promotional package to surgeons containing this marketing pitch: “In today's cost-conscious environment improved patient care is no longer the sole consideration — especially when health care dollars must go farther than ever before.” Freed from the unreasonable burden of improved patient care, the modern plastic surgeon can sit back in his chair, put the patient on hold and let a smooth-talking prerecorded pitchman sell another cosmetic procedure.

With all of the practice-building, it's no wonder that many patients have trouble paying for their surgery. Booth 8A offers the answer — the AMS Patient Financing Program, which allows patients to go under the knife and into hock all in the same day. Patients receive “competitive interest rates” (which, at 18 percent, is competitive with the crappiest credit cards) entitling them to the surgical procedures they want “when they want them.” As a pamphlet explains to surgeons: “The Program offers you the potential for 100 percent payment prior to surgery, which could be a real boost to your office cash flow!”

Even with generous financing, some patients are deadbeats. The Conomikes Reports, a medical management newsletter making the rounds at the convention, presents these suggestions for plastic surgeons trying to collect outstanding bills: “Ask for the payment in full, no matter how big the bill”; “Create urgency. Let them know they need to pay the bill now.”

Hippocrates had it all wrong: First, get the money up front.

The cleanup after a major convention resembles the pack-it-up-and-tear-it-down following a rock concert, except that no one plays Jackson Browne, thank God. After the last plastic surgeon drifts from the exhibit hall, a team of long-haired roadies working for that minimum wage begin dismantling the booths. All of the merchandise is packed in huge wooden crates for the next show — tiny piles of plastic chin implants, stacks of company pamphlets crammed with practice-building tips, boxes of plastic syringes, heaving mounds of chalky white breast implants, and all of those before and after photos. The McGhan exhibit booth, so impressive during the show with its colorful illuminated panels proudly announcing three major breast-implant studies, is partially dissembled, revealing a cheap plywood backing.

A trash can in the front of the hall bulges with the nasty dregs of the convention — plastic coffee cups, smeared napkins, a half-eaten cookie, a discarded name tag and — hold on, what's this? A small uncooked club steak? It's the steak still bearing the scars of the surgery inflicted by the savage cutting power of the Surgitron radiosurgical scalpel. It isn't hard to guess why it was left behind. These days, plastic surgery can always find another piece of meat.